Boeing executives failed at leadership, forgot the lessons of lean

In January of this year, passengers, crew and the general public were shocked by yet another high-profile incident involving a Boeing 737 MAX-9 jet. The door plug blew out during an Alaska Airlines flight at 16,000 feet. Fortunately (and perhaps luckily), no one died in the incident.

After the event, people may ask: "Who screwed up?" Better questions include: "What is going wrong in Boeing's processes and operations?" We should also ask: "What is wrong with Boeing's culture and leadership?"

Are these new, isolated problems with new, local causes? It seems not.

Immediately after the incident, inspections of the temporarily grounded MAX-9s led to the discovery of loose bolts on several jets in the United Airlines fleet. The fact that the problem was not isolated to a single airplane makes it even clearer that this is a systemic problem — certainly not the fault of any individual mechanic or team.

Initially, it was assumed that the bolts on the Alaska Airlines plane had come loose, but a preliminary NTSB report confirmed what started as an internet rumor: the four bolts in question had not been reinstalled. They were missing altogether, presumably left on a workbench or thrown in the trash.

Why?

The door plug, originally installed on the fuselage by supplier Spirit AeroSystems, had been removed at a Boeing facility in Washington and needed to be reinstalled.

Why?

Boeing and Spirit employees had to rework the fuselage due to riveting defects created during Spirit's manufacturing process in Kansas. Spirit should be asking why those defects occurred and how they can prevent them from happening again. But responsibility for the incident does not end with Spirit.

Boeing CEO David Calhoun, who in March announced his retirement by the end of 2024, said publicly: "We caused the problem, and we understand that... Boeing is accountable for what happened." It is a company problem, and Boeing is responsible for the work of its suppliers.

But how could the mechanics forget to reinstall the bolts after putting the door plug back in place? Instead of blaming and potentially punishing individuals or blaming "some idiot," it is important to look at the systemic causes and the driving factors for which Boeing should hold itself accountable. Again, it is a company problem, not a worker problem.

The rework was being done outside the normal process. Why? It was part of a widespread practice at Boeing referred to as "traveled work," which the company defines as tasks "that are behind schedule and/or are completed in a factory location other than the one originally planned."

This practice violates the lean principles of:

• Building quality in at the source
• Not passing defective parts or products forward to be fixed later down the line.

"Traveled work" is less likely to follow standardized work or to have the tools normally used at the workstation itself. Boeing says that documentation of the door plug reinstallation was missing (or never existed). And reports indicate that security camera footage of the area was overwritten and lost.

It is worrying that such important work was carried out outside the process and without documentation. But in a way, this is good if it means the company does not know which individual (or individuals) to punish, because the problem was effectively caused by Boeing's policies and practices.

Boeing CFO Brian West said: “Starting March 1, 2024, we will no longer do traveled work between Wichita and our fuselage supplier [Spirit AeroSystems] and Renton [Boeing's assembly plant]... This had been going on for far too long. So now we will only accept fully conforming fuselages from Spirit, which means that in the short term there may be supply variability.”

The lean experts who taught Boeing about the Toyota Production System surely instructed the company to put quality first, even if it means stopping the line to address defects instead of passing them on. Decades later, has Boeing forgotten that lesson or refused to implement it?

CEO Calhoun admitted that the amount of rework taking place in Boeing's so-called "shadow factories" exceeded the initial labor hours, stating: “In our shadow factories, we put more labor hours into the airplanes than the hours needed to produce them initially... that is a metric I know everyone understands.” That metric is understandable, but it is utterly astonishing to hear of any factory spending more time on rework than on production.

So why didn't Calhoun and other leaders do anything about it?

West's comment about "supply variability" suggests that putting quality first may lead to production delays and late deliveries. In a lean culture, short-term production delays should trigger root-cause problem solving, which should lead to countermeasures that drive long-term improvements. Passing defective work forward is a temporary fix — and it is extremely counterproductive over time.

Reducing that supply variability — and the resulting variation in aircraft assembly — must go beyond Boeing rejecting a delivered fuselage that does not fully conform to specifications. The company must work with its suppliers to help them implement the lean methods and mindset that prevent errors and build quality into their factories (those of suppliers or sub-suppliers). Part of Toyota's formula for success is its collaborative relationships with its suppliers. You cannot simply demand better quality from them; instead, you must work together from the product design and supplier selection phases throughout the full life cycle of an airplane.

Lean organizations do not just talk about putting safety and quality first; they demonstrate it in the boardroom and on the shop floor. Point number one of the "Toyota Way" says that the company makes decisions based on the long term, even if this comes at a short-term cost. That is another lesson Boeing has forgotten or never adopted.

For years, Boeing employees and critics have complained about a culture where "schedule is king." In other words, frontline employees and leaders are pressured to keep the line moving — that is, to emphasize and prioritize quantity over quality.

CFO West also admitted: "For years, we prioritized moving the airplane through the factory over getting things right, and that has to change."

If executives were unaware of these practices, which emphasized production quantity and flow over safety and quality, they should be (and have been) held accountable. If leaders directly drove (or tolerated) these priorities, that is grounds for dismissal.

CEO Calhoun acknowledges that Boeing "must embed a total commitment to safety and quality at every level of our company." If he has not done so in the last four years, he needs to go — AS SOON AS POSSIBLE, and not at the end of 2024 as announced — for Boeing's culture to change.

There are many cases of "too little and/or too late" admissions by Boeing's leaders. Shortly after the incident, Boeing announced "quality stand-down days," to "allow all employees who interact with the airplanes to 'pause, evaluate what we are doing, how we do it and propose recommendations for improvement,'" said Stan Deal, president and CEO of Boeing Commercial Aviation — forced to retire in March.

Why limit such reflections to frontline employees? Did Boeing's Board and senior executives set aside a day to stop and reflect on their role in safety and quality? During the stand-down day, "10,000 participating employees were encouraged to speak up about any concerns they had and offer suggestions on ways to improve the facility's processes."

It seems to be a tacit admission that Boeing had also not learned (or refused to adopt) the basic lean principles and practices of involving everyone in continuous improvement. How many of those ideas will be implemented?

Changing a problematic corporate culture requires bringing in new leaders from outside. To prevent future incidents such as door plugs blowing out and similar manufacturing problems, Boeing's executives must embrace, encourage and reward the following behaviors:

• Every leader prioritizing safety, quality, delivery and cost — in that order, every day.
• Stopping production to fix quality problems, using rigorous problem-solving methods, instead of transferring them to another facility or rework area.
• Involving every team member in continuous improvement every day, soliciting ideas and acting on them continuously, instead of waiting for a kaizen event or another "stand down".

It is long past time for Boeing to learn and embrace the lean lessons of Toyota and other world-class manufacturers.